| Section Name |
Field Name |
Field and/or Section Description |
| TITLE ACORD 126 (2009/08) |
Commercial General Liability
Section |
The title of the form. ACORD 126, Commercial General Liability Section, is a form of
insurance designed to protect owners and operators of businesses from a
wide variety of liability exposures. These exposures include liability
for accidents resulting from the insured’s operations or premises,
products sold or operations completed by the insured, and contractual
liability. The Coverage and Limits Section of the ACORD 126 was
designed to follow the ISO Policy Simplification Program first
initiated in 1986. The ACORD 126 was designed to be used in conjunction
with the Commercial Insurance Application
-Applicant Information Section (ACORD 125). Please refer to the chapter
on the ACORD 125 for information on that form. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number
assigned by the producer (e.g. agency or brokerage). |
| IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is
completed. (MM/DD/YYYY) |
| IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
| IDENTIFICATION SECTION |
Policy Number |
Enter identifier: The identifier assigned by the insurer to
the policy, or submission, being referenced exactly as it appears on
the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number. |
| IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that
the terms and conditions of the policy commence. |
| IDENTIFICATION SECTION |
Carrier |
Enter text: The insurer’s full legal company name(s) as found
in the file copy of the policy. Use the
actual name of the company within the group to which the policy has
been issued. This is not the insurer’s group name or trade name. |
| IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer
by the NAIC. |
| IDENTIFICATION SECTION |
Applicant / First Named Insured |
Enter text: The named insured(s) as it/they will appear on
the policy declarations page. |
| COVERAGES |
Commercial General Liability |
Check the box (if applicable): Indicates the claims made or
occurrence option applies for the general liability policy. |
| COVERAGES |
Claims Made |
Check the box (if applicable): Indicates the “claims made”
option applies on the general liability policy. |
| COVERAGES |
Occurrence |
Check the box (if applicable): Indicates the general
liability policy, occurrence basis applies. |
| COVERAGES |
Owner’s & Contractors Protective |
Check the box (if applicable): Indicates the owners and
contractors protective option applies for the general liability policy. |
| COVERAGES |
Other checkbox |
Check the box (if applicable): Indicates other coverage not
found on the form exists for the general liability policy. |
| COVERAGES |
Other Field |
Enter text: The description of other coverage (not the limit)
on the general liability policy. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing
insurer(s). |
| COVERAGES |
Deductibles-Property Damage checkbox |
Check the box (if applicable): Indicates if a property damage
deductible is requested. |
| COVERAGES |
Property Damage |
Enter amount: The deductible applicable to the Property
Damage coverage. |
| COVERAGES |
Bodily Injury checkbox |
Check the box (if applicable): Indicates if a bodily injury
deductible is requested. |
| COVERAGES |
Bodily Injury |
Enter amount: The deductible applicable to the Bodily Injury
coverage. |
| COVERAGES |
Other checkbox |
Check the box (if applicable): Indicates that a deductible is
requested on the coverage other than Property Damage or Bodily Injury. |
| COVERAGES |
Other Field |
Enter text: The type of deductible being requested other than
property damage and bodily injury. |
| COVERAGES |
Other |
Enter amount: The deductible applicable to the Other Coverage. |
| COVERAGES |
Per Claim checkbox |
Check the box (if applicable): Indicates that a per claim
deductible applies to individual claims even if the claims are all
related to the same occurrence or event. |
| COVERAGES |
Per Occurrence checkbox |
Check the box (if applicable): Indicates that a per
occurrence deductible applies once to each occurrence no matter how
many individual claims result from the occurrence or event. |
| LIMITS |
General Aggregate |
Enter limit: The general liability, general aggregate limit
amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s). |
| LIMITS |
Limit Applies per Policy (check box) |
Check the box (if applicable): Indicates the general
liability policy, general aggregate limit applies per policy. |
| LIMITS |
Project (check box) |
Check the box (if applicable): Indicates the general
liability policy, general aggregate limit applies per project. |
| LIMITS |
Location (check box) |
Check the box (if applicable): Indicates the general
liability policy, general aggregate limit applies per location. |
| LIMITS |
Other: (check box) |
Check the box (if applicable): Indicates the general
liability policy, general aggregate limit applies to code is other than
those listed. |
| LIMITS |
Other Description |
Enter code: The limit applies to code for the general
liability policy, general aggregate limit. |
| LIMITS |
Products & Completed Operations Aggregate $ Field |
Enter limit: The general liability, products and completed
operations aggregate limit amount. Any questions about appropriate
limits or applicable policy coverage(s) should be answered by the
issuing insurer(s). |
| LIMITS |
Personal & Advertising Injury |
Enter limit: The general liability, personal and advertising
injury limit amount. Any questions about appropriate limits or
applicable policy coverage(s) should be answered by the issuing
insurer(s). |
| LIMITS |
Each Occurrence |
Enter limit: The general liability, each occurrence limit
amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s). |
| LIMITS |
Damage to Rented Premises |
Enter limit: The general liability, damage to rented premises
each occurrence limit amount. Any questions about appropriate limits or
applicable policy coverage(s) should be answered by the issuing
insurer(s). |
| LIMITS |
Medical Expense |
Enter limit: The general liability, medical expense each
person limit amount. Any questions about appropriate limits or
applicable policy coverage(s) should be answered by the issuing
insurer(s). |
| LIMITS |
Employee Benefits |
Enter limit: The general liability employee benefits limit
amount. |
| LIMITS |
Other Limit Description |
Enter text: The description of other coverage (not the
limit). Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s). |
| LIMITS |
Other Limit |
Enter limit: The general liability, other coverage limit
amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s). |
| LIMITS |
Premiums-Premises/Operations |
Enter amount: The premium for premises/operations coverage. |
| LIMITS |
Products |
Enter amount: The premium for products coverage. |
| LIMITS |
Other |
Enter amount: The premium for other general liability
coverage. |
| LIMITS |
Total |
Enter amount: The total premium amount for the commercial
general liability line of business. |
| LIMITS |
Other Coverages, Restrictions and/or Endorsements |
Enter text: The remarks associated with the general liability
line of business. Use this section to provide any additional
information required for underwriting or rating. Attach ACORD 101,
Additional Remarks Schedule, is more space is required. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| SCHEDULE OF HAZARDS |
Location # |
Enter number: The producer assigned identifier for the
location number of the risk’s location as it appears on the Applicant
Information Section of ACORD 125. All classifications should be grouped
by location number. |
| SCHEDULE OF HAZARDS |
Hazard # |
Enter number: A unique (within location) number
distinguishing this unit-at-risk from the others. |
| SCHEDULE OF HAZARDS |
Classification |
Enter text: The classification the applicant’s liability
exposures by location, using the ISO Classification Table or other
industry organization rules. Enter the appropriate class description
from the table in this field. |
| SCHEDULE OF HAZARDS |
Class Code |
Enter code: The general liability class code that corresponds
to the classification description shown in the previous field. |
| SCHEDULE OF HAZARDS |
Premium Basis |
Enter code: An industry code designating the rating basis of
the exposure amount. |
| SCHEDULE OF HAZARDS |
Exposure |
Enter amount: The amount of the exposure used for this class
code in calculating the premium. The contents of this data element
depends on the rating basis used. The full amount of exposure is
contained. |
| SCHEDULE OF HAZARDS |
Terr. |
Enter code: The rating territory code based on location from
the appropriate state exception page. |
| SCHEDULE OF HAZARDS |
Rate – Prem/Ops |
Enter rate: The separate Premises Operations manual rate
applicable to the classification. |
| SCHEDULE OF HAZARDS |
Rate – Products |
Enter rate: The separate Products rate applicable to the
classification. |
| SCHEDULE OF HAZARDS |
Premium – Prem/Ops |
Enter amount: The premium associated with the premises
operations coverage. |
| SCHEDULE OF HAZARDS |
Premium – Products |
Enter amount: The premium associated with the products
coverage. |
| CLAIMS MADE |
1. Proposed Retroactive Date |
Enter date: The retroactive date you are requesting for the
policy being applied for. This is the proposed earliest date for which
an occurrence could “trigger” coverage under a Claims Made policy. |
| CLAIMS MADE |
2. Entry date into uninterrupted claims made coverage |
Enter date: The retroactive date shown on the applicant’s
first Claims Made policy. If this is the first such policy, the date
will be the same as the proposed retroactive date shown on the
preceding field. If this is a renewal, it is the effective date of the
first policy issued in the sequence of uninterrupted Claims Made
policies. |
| CLAIMS MADE |
3. Has any product, work, accident or location been excluded,
uninsured or self-insured from any previous coverage?-Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Has any product, work, accident or location
been excluded, uninsured or self-insured from any previous coverage?”. |
| CLAIMS MADE |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| CLAIMS MADE |
4. Was tail coverage purchased under any previous policy?-Yes
checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Was tail coverage purchased under any
previous policy?”. |
| CLAIMS MADE |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| EMPLOYEE BENEFITS LIABILITY |
Deductible Per Claim: |
Enter deductible: The deductible per claim applicable to
Employee Benefits Liability coverage. |
| EMPLOYEE BENEFITS LIABILITY |
Number of Employees: |
Enter number: The total number of employees. |
| EMPLOYEE BENEFITS LIABILITY |
Number of Employees Covered By Employee Benefits Plan: |
Enter number: The total number of employees covered by
employee benefits plans. |
| EMPLOYEE BENEFITS LIABILITY |
Retroactive Date: |
Enter date: The retroactive date that is the earliest date
for which an occurrence could “trigger” coverage under Employee
Benefits coverage. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number
assigned by the producer (e.g. agency or brokerage). |
| CONTRACTORS |
1. Does applicant draw plans, designs, or specifications for
others? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Does applicant draw plans, designs or
specifications for others?”. |
| CONTRACTORS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| CONTRACTORS |
2. Do any operations include blasting or utilize or store
explosive material? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Do any operations include blasting or
utilize, or store explosive material?”. |
| CONTRACTORS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| CONTRACTORS |
3. Do any operations include evacuation, tunneling,
underground work or earth moving? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Does any operation involve excavation,
tunneling, underground work or earth moving?”. |
| CONTRACTORS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| CONTRACTORS |
4. Do your subcontractors carry coverages or limits less than
yours? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Do subcontractors carry coverages or limits
less than applicant?”. |
| CONTRACTORS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| CONTRACTORS |
5. Are subcontractors allowed to work without providing you
with Certificates of Insurance? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Are subcontractors allowed to work without
providing you with a certificate of insurance?”. |
| CONTRACTORS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| CONTRACTORS |
6. Does applicant lease equipment to others with or without
operators? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Does applicant lease equipment to others
with or without operators?”. |
| CONTRACTORS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| CONTRACTORS |
$ Paid to Subcontractors |
Enter amount: The total dollar amount for work that the
contractor pays to subcontractors. |
| CONTRACTORS |
% of Work Subcontracted |
Enter percentage: The percentage of the work described by the
applicant as subcontracted out. |
| CONTRACTORS |
# Full Time Staff |
Enter number: The number of individuals employed full time by
the applicant. |
| CONTRACTORS |
# Part Time Staff |
Enter number: The number of individuals employed part time by
the applicant. |
| CONTRACTORS |
Remarks/Describe the type of work & percentage
subcontracted |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
Products |
Enter text: The name used to identify the product
manufactured or sold or service provided by the applicant. |
| PRODUCTS/COMPLETED OPERATIONS |
Annual Gross Sales |
Enter amount: The whole dollar estimate of the annual sales
receipts realized by this product or service. |
| PRODUCTS/COMPLETED OPERATIONS |
# of Units |
Enter number: The number of units of this product
manufactured and/or sold each year. |
| PRODUCTS/COMPLETED OPERATIONS |
Time in Market |
Enter number: The number of months the product or service has
been marketed to the public. |
| PRODUCTS/COMPLETED OPERATIONS |
Expected Life |
Enter number: The anticipated number of months of useful life
of the product or service. |
| PRODUCTS/COMPLETED OPERATIONS |
Intended Use |
Enter text: The intended use of the product. |
| PRODUCTS/COMPLETED OPERATIONS |
Principal Components |
Enter text: The principal components of the product. |
| PRODUCTS/COMPLETED OPERATIONS |
Products |
Enter text: The name used to identify the product
manufactured or sold or service provided by the applicant. |
| PRODUCTS/COMPLETED OPERATIONS |
Annual Gross Sales |
Enter amount: The whole dollar estimate of the annual sales
receipts realized by this product or service. |
| PRODUCTS/COMPLETED OPERATIONS |
# of Units |
Enter number: The number of units of this product
manufactured and/or sold each year. |
| PRODUCTS/COMPLETED OPERATIONS |
Time in Market |
Enter number: The number of months the product or service has
been marketed to the public. |
| PRODUCTS/COMPLETED OPERATIONS |
Expected Life |
Enter number: The anticipated number of months of useful life
of the product or service. |
| PRODUCTS/COMPLETED OPERATIONS |
Intended Use |
Enter text: The intended use of the product. |
| PRODUCTS/COMPLETED OPERATIONS |
Principal Components |
Enter text: The principal components of the product. |
| PRODUCTS/COMPLETED OPERATIONS |
Products |
Enter text: The name used to identify the product
manufactured or sold or service provided by the applicant. |
| PRODUCTS/COMPLETED OPERATIONS |
Annual Gross Sales |
Enter amount: The whole dollar estimate of the annual sales
receipts realized by this product or service. |
| PRODUCTS/COMPLETED OPERATIONS |
# of Units |
Enter number: The number of units of this product
manufactured and/or sold each year. |
| PRODUCTS/COMPLETED OPERATIONS |
Time in Market |
Enter number: The number of months the product or service has
been marketed to the public. |
| PRODUCTS/COMPLETED OPERATIONS |
Expected Life |
Enter number: The anticipated number of months of useful life
of the product or service. |
| PRODUCTS/COMPLETED OPERATIONS |
Intended Use |
Enter text: The intended use of the product. |
| PRODUCTS/COMPLETED OPERATIONS |
Principal Components |
Enter text: The principal components of the product. |
| PRODUCTS/COMPLETED OPERATIONS |
1. Does applicant install, service or demonstrate products?
Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Does applicant install, service or
demonstrate products?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
2. Foreign products sold, distributed, or used as components?
Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Foreign products, sold, distributed, used as
components?”. |
| PRODUCTS/COMPLETED OPERATIONS |
3. Research and development conducted or new products
planned? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Research and development conducted or new
products planned?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
4. Guarantees, warranties, hold harmless agreements? Yes
checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Guarantees, warrantees, hold harmless
agreements?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
5. Products related to aircraft/space industry? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Products related to aircraft/space
industry?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
6. Products recalled, discontinued, changed? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Products recalled, discontinued, changed?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
7. Products of others sold or repackaged under applicant’s
label? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Products of others sold or repackaged under
applicant label?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
8. Products under label of others? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Products under label of others?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
9. Vendor’s coverage required? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Vendors coverage required?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| PRODUCTS/COMPLETED OPERATIONS |
10. Does any named insured sell to any other named insured?
Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Does any named insured sell to other named
insured?”. |
| PRODUCTS/COMPLETED OPERATIONS |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number
assigned by the producer (e.g. agency or brokerage). |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
ACORD 45 attached for additional names checkbox |
Check the box (if applicable): Indicates that further
additional interests appear on the attached ACORD 45. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Interest-Additional Insured |
Check the box (if applicable): Indicates the additional
interest type is an additional insured. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Employee as Lessor |
Check the box (if applicable): Indicates the additional
interest type is an employee as lessor. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Lienholder |
Check the box (if applicable): Indicates the additional
interest type is a lien holder. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Loss payee |
Check the box (if applicable): Indicates the additional
interest type is a loss payee. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Mortgagee |
Check the box (if applicable): Indicates the additional
interest type is a mortgagee. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Other checkbox |
Check the box (if applicable): Indicates the additional
interest is not any of the types listed on the form. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Other Field |
Enter text: The description of the type of interest in the
item. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Rank |
Enter number: The ranking of ‘this’ additional interest when
multiple additional interests are associated with the same item. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Certificate Required Checkbox |
Check the box (if applicable): Indicates if the additional
interest requires a Certificate of Insurance, |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Name & Address |
Enter text: The additional interest’s full name. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
|
Enter text: The additional interest’s mailing address line
one. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
|
Enter text: The additional interest’s mailing address line
two. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
|
Enter text: The additional interest’s mailing address city
name. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
|
Enter code: The additional interest’s mailing address state
or province code. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
|
Enter code: The additional interest’s mailing address postal
code. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
|
Enter code: The additional interest’s country code. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Reference # |
Enter identifier: The loan number, account number or other
controlling number that the additional interest may have assigned the
insured. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Interest in Item Number – Location: |
Enter number: The producer assigned number of the location
which has an additional interest. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Building: |
Enter number: The producer assigned number of the building
which has an additional interest. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Item Class |
Enter text: The description of the property class of the
scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.). |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Item: |
Enter number: The producer assigned number of the scheduled
item which has an additional interest. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Item Description |
Enter text: The description of the item of interest if needed
to further clarify. For a vehicle, list the make, model and VIN number.
For a scheduled item, list the description, such as three carat diamond
in six point setting. |
| GENERAL INFORMATION |
1. Any medical facilities provided or medical professionals
employed or contracted? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Any medical facilities provided or medical
professionals employed or contracted?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
2. Any exposure to radioactive/nuclear materials? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Any exposure to radioactive/nuclear
materials?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
3. Do operations involve storing, treating, discharging,
applying, disposing or transporting hazardous material? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Do/have past, present or discontinued
operations involve(d) storing, treating, discharging, applying,
disposing, or transporting of hazardous material?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
4. Any listed operations sold, acquired, or discontinued in
the last five (5) years? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Any operations sold, acquired or
discontinued in the last specified number of years?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
5. Is any machinery or equipment loaned or rented to others?
Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Machinery or equipment loaned or rented to
others?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
6. Any watercraft, docks, floats owned, hired, or leased? Yes
checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Any watercraft, docks, floats owned, hired
or leased?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
7. Any parking facilities owned/ rented? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Any parking facilities owned/rented?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
8. Is a fee charged for parking? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Is a fee charged for parking?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
9. Are any recreational facilities provided? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Recreation facilities provided?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
10. Is there a swimming pool on the premises? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Is there a swimming pool on the premises?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
11. Any sporting or social events sponsored? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Sporting or social events sponsored?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
12. Any structural alterations contemplated? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Any structural alterations contemplated?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
13. Any demolition exposure contemplated? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Any demolition exposure contemplated?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
14. Has applicant been active in or is currently active in
joint ventures? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Has applicant been active in or is currently
active in joint ventures?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
15. Do you lease employees to or from others? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Do you lease employees to or from other
employers?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number
assigned by the producer (e.g. agency or brokerage). |
| GENERAL INFORMATION |
16. Is there a labor interchange with any other business or
subsidiaries? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Is there a labor interchange with any other
business or subsidiaries?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
17. Are daycare facilities operated or controlled? Yes
checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Are day care facilities operated or
controlled?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
18. Have any crimes occurred or been attempted on your
premises within the last three (3) years? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Have any crimes occurred or been attempted
on your premises within the last specified number of years?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
19. Is there a formal, written safety and security policy in
effect? Yes checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Is there a formal, written safety and
security policy in effect?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
20. Does the businesses’ promotional literature make any
representations about the safety or security of the premises? Yes
checkbox |
Enter Y for a “Yes” response. Input N for “No” response. The
response to the question, “Does the business’ promotional literature
make any representation about the safety or security of the premises?”. |
| GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general
information or underwriting question. Normally, “Yes” responses require
an explanation. |
| GENERAL INFORMATION |
REMARKS |
Enter text: The remarks associated with the general liability
line of business. Use this section to provide any additional
information required for underwriting or rating. Attach ACORD 101,
Additional Remarks Schedule, if more space is required. |
| Edition |
Date |
The edition identifier of the form including the form number
and edition (the date is typically formatted YYYY/MM). |
No comments:
Post a Comment